The impact of hospital nursing characteristics on 30-day mortality.

BACKGROUND: Evidence indicates that hospital nursing characteristics such as staffing contribute to patient outcomes. Less attention has been given to other hospital nursing characteristics central to optimal professional practice, namely nurse education and skill mix, continuity of care, and quality of the work environment. OBJECTIVE: To assess the relative effects and importance of nurse education and skill mix, continuity of care, and quality of work environment in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics. METHOD: A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, Canada, for diagnoses of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke between April 1, 1998, and March 31, 1999, was done. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals. RESULTS: Using multilevel analysis, it was determined that the log-odds for 30-day mortality varied significantly across hospitals (variance .044, p < .001). Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching, and urban status of the study hospitals in a fixed-effects model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics that predict 30-day mortality were as follows: 0.81 (0.68-0.96) for higher nurse education level, 0.83 (0.73-0.96) for richer nurse skill mix, 1.26 (1.09-1.47) for higher proportion of casual or temporary positions, and 0.74 (0.6-00.91) for greater nurse-physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%. DISCUSSION: Hospital nursing characteristics are an important consideration in efforts to reduce the risk of 30-day mortality of patients.

Workplace violence in Alberta and British Columbia hospitals.

Workplace violence is a significant and widespread public health concern among health care workers, including nurses. With growing awareness of how practice environments influence patient outcomes and the retention of health professionals, it is timely to consider the impact of workplace violence in hospitals. Registered nurses in Alberta and British Columbia, Canada were surveyed on their experiences of violence in the workplace over the last five shifts. Our results suggest that nurses are experiencing many incidences of violence in a given work week, particularly in the emergency, psychiatric, and medical-surgical settings. Most violent acts are perpetrated by patients, but there is also a significant portion of violence and abuse committed by hospital co-workers, particularly emotional abuse and sexual harassment. Our results also indicate that the majority of workplace violence is not reported. We suggest that using the Broken Windows theory might be a useful tool to conceptualize why workplace violence occurs, and that this framework be used to begin to develop new violence prevention policies and strategies.

Nurse specialty subcultures and patient outcomes in acute care hospitals: A multiple-group structural equation modeling.

BACKGROUND: Hospital organizational culture is widely held to matter to the delivery of services, their effectiveness, and system performance in general. However, little empirical evidence exists to support that culture affects provider and patient outcomes; even less evidence exists to support how this occurs. OBJECTIVES: To explore causal relationships and mechanisms between nursing specialty subcultures and selected patient outcomes (i.e., quality of care, adverse patient events). METHOD: Martin's differentiation perspective of culture (nested subcultures within organizations) was used as a theoretical framework to develop and test a model. Hospital nurse subcultures were identified as being reflected in formal practices (i.e., satisfactory salary, continuing education, quality assurance program, preceptorship), informal practices (i.e., autonomy, control over practice, nurse-physician relationships), and content themes (i.e., emotional exhaustion). A series of structural equation models were assessed using LISREL on a large nurse survey database representing four specialties (i.e., medical, surgical, intensive care, emergency) in acute care hospitals in Alberta, Canada. RESULTS: Nursing specialty subcultures differentially influenced patient outcomes. Specifically, quality of care (a) was affected by nurses' control over practice, (b) was better in intensive care than in medical specialty, and (c) was related to lower adverse patient events; nurses in intensive care and emergency specialties reported fewer adverse events than did their counterparts in medical specialties. CONCLUSIONS: Understanding the meaning of subcultures in clinical settings would influence nurses and administrators efforts to implement clinical change and affect outcomes. More research is needed on nested subcultures within healthcare organizations for better understanding differentiated subspecialty effects on complexity of care and outcomes in hospitals.

Nursing scope of practice: descriptions and challenges.

The nursing workforce is faced with shortages of near crisis proportions, yet little is understood about the optimal utilization of various categories of nurses - Licensed Practical Nurses (LPNs), Registered Nurses (RNs) and Registered Psychiatric Nurses (RPNs). The primary purpose in this study was to elicit the perceptions of nurses (RNs, LPNs, and RPNs) of what "working to full scope of practice" meant to them. Participants included acute care nurses in three health regions in western Canada. A key finding from the study was the fact that nurses most often discussed scope of practice by reference to the tasks they perform, rather than the roles they play in healthcare delivery. Assessment and coordination of care were two components of nursing work that most differentiated the three nursing roles. Nonetheless, insufficient role differentiation among nurses and between nurses and other healthcare professionals leaves some nurses feeling devalued and not respected for their contribution to healthcare delivery.

Nursing workforce utilization: an examination of facilitators and barriers on scope of practice.

Several reports have highlighted the need to address underutilization of health human resources, but barriers to and facilitators of role optimization for nurses are poorly understood. The purpose in this study was to understand the perceptions of nurses - Licensed Practical Nurses (LPNs), Registered Nurses (RNs) and Registered Psychiatric Nurses (RPNs) - of the extent to which they can work to full scope of practice and identify barriers and facilitators in optimizing their roles. As part of a mixed-methods study, semi-structured interviews were conducted with 167 acute care nurses (RNs, LPNs, RPNs and nurse managers) in three western Canadian health regions. Approximately 48% of all nurses interviewed felt they were working to full scope, at least some of the time. Barriers to working to full scope included heavy workload, high patient acuity, lack of time, poor communication and ineffective teamwork. Identified facilitators were working as a team, management and leadership support and support for continuing education. Barriers need to be addressed in light of nursing shortages, as these are closely related to job satisfaction and directly affect the retention and recruitment of all groups of nurses. Policies and strategies based on these findings must be developed to ensure that nurses can work to their full scope of practice.

The impact of hospital nursing characteristics on 30-day mortality.

BACKGROUND: Evidence indicates that hospital nursing characteristics such as staffing contribute to patient outcomes. Less attention has been given to other hospital nursing characteristics central to optimal professional practice, namely nurse education and skill mix, continuity of care, and quality of the work environment. OBJECTIVE: To assess the relative effects and importance of nurse education and skill mix, continuity of care, and quality of work environment in predicting 30-day mortality after adjusting for institutional factors and individual patients characteristics. METHOD: A cross-sectional analysis of outcome data for 18,142 patients discharged from 49 acute care hospitals in Alberta, Canada, for diagnoses of acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, or stroke between April 1, 1998, and March 31, 1999, was done. Mortality data were linked to patient demographic and comorbidity factors, institutional characteristics, and hospital nursing characteristics derived from a survey of all registered nurses working in acute care hospitals. RESULTS: Using multilevel analysis, it was determined that the log-odds for 30-day mortality varied significantly across hospitals (variance = .044, p < .001). Patient comorbidities and age explained 44.2% of the variance in 30-day mortality. After adjustment for patient comorbidities and demographic factors, and the size, teaching, and urban status of the study hospitals in a fixed-effects model, the odds ratios (95% confidence interval) of the significant hospital nursing characteristics that predict 30-day mortality were as follows: 0.81 (0.68-0.96) for higher nurse education level, 0.83 (0.73-0.96) for richer nurse skill mix, 1.26 (1.09-1.47) for higher proportion of casual or temporary positions, and 0.74 (0.60-0.91) for greater nurse-physician relationships. The institutional and hospital nursing characteristics explained an additional 36.9%. DISCUSSION: Hospital nursing characteristics are an important consideration in efforts to reduce the risk of 30-day mortality of patients.

Measuring the hospital practice environment: a Canadian context.

The primary purpose of this study is to document the psychometric properties of the revised Nursing Work Index (NWI-R) in the context of a large Canadian sample of registered nurses. A self-administered survey containing the NWI-R was completed by 17,965 registered nurses working in 415 hospitals in three Canadian provinces. Using exploratory principal components analysis, with a forced one-factor solution, the practice environment index was obtained. In addition, key assumptions were tested from previous work about the rationale for the aggregation of NWI-R responses. In the Canadian context the one-factor solution provides a parsimonious index of the practice environment of registered nurses working in acute care hospitals. Further work is needed to determine the predictive capability of this index and its relevance to cross-national organizational contexts.